Scope of Practice

Primer on Standing Orders for Immunizations and Emergency Treatment of Anaphylaxis

Introduction

Effective September 19, 2000, the Board of Regents approved regulations implementing a law passed in 1999 allowing registered professional nurses to carry and administer immunizations and agents used in the emergency treatment of anaphylaxis in accordance with standing orders (non-patient specific orders) and protocols.

Prerequisites

All RNs involved in the administration of immunizing agents in accordance with a non-patient specific standing order and protocol must be certified in CPR utilizing an American Red Cross, American Heart Association or equivalent organization program.

Authorized Immunizing Agents

The list of authorized immunizing agents differs for adults and children. Adults are persons who are 18 years of age or older. Children are persons under 18 years of age.

Adults: Hepatitis A, Hepatitis B, Influenza, Pneumococcus, Meningococcus, Diphtheria, Tetanus, Measles, Mumps, Rubella, Varicella, Inactivated Polio, and any additional agents approved by the Board of Regents.*

Children: Diphtheria, Tetanus, Acellular Pertussis, Measles, Mumps, Rubella, Vericella, Haemophilus Influenza Type b (HIB), Inactivated Polio, Hepatitis B, and any additional agents approved by the Board of Regents.*

*The Board of Regents plans to add and remove authorized immunizing agents in accordance with the recommendations of the Centers for Disease Control and Prevention and the NYS Department of Health.

Epidemics

Any registered nurse who is CPR certified is authorized to administer any immunizing agent that is authorized by a non-patient specific standing order and protocol as part of an immunization program authorized, maintained or under the auspices of the state Commissioner of Health, a county commissioner of health, or county public health director when the immunization program is instituted as a result of an epidemic declared by any of these public health officials.

Requirements for Administration of Immunizations Using Non-Patient Specific Orders and Protocols  

Adults and Children:

• All RNs must follow non-patient specific standing orders and protocols authorized by a physician or a certified nurse practitioner.
• All RNs must maintain or ensure the maintenance of a copy of the standing order(s) and protocol(s) that authorizes them to administer immunizations. 

The non-patient specific standing orders for immunizations must contain: 

• Language authorizing RNs to administer immunizations;
• The name(s) and license number(s) of RNs individually authorized to administer the prescribed immunizations or
• The name of the entity that is legally authorized to employ or contract with RNs to provide nursing services (eliminating the need to name all RNs individually), including administering prescribed immunizations;
• A statement that RNs not named individually can not administer immunizations outside of this employment or contract situation using this standing order or protocol;
• The specific immunizing agents that the RN(s) are authorized to administer;
• The period of time that the order is effective, including beginning and ending dates;
• A protocol prescribing actions to be taken by the authorized RNs when administering immunizations in accordance with the non-patient specific standing order;
• The name, license number and signature of the prescribing physician or certified nurse practitioner. 

The protocol to administer immunizations must require the RN to: 

• Ensure the potential recipient is assessed for contraindications to immunizations;
• Inform each potential immunization recipient of the potential side effects and adverse reactions, orally and in writing, prior to immunization;
• Inform each potential immunization recipient, in writing, of the appropriate course of action in the event of an untoward or adverse event. Vaccine Information Statements (VIS) developed by the CDC are recommended for this use;
• Obtain consent for the immunization from the potential recipient or a person legally responsible in the case of a minor or otherwise incapable person before the immunization is administered. In cases of minors and persons incapable of personally consenting to immunization, consent may be gained by informing the legally responsible person of the information noted above in writing and obtaining a written consent or by informing them of this information in person at the site of the immunization and obtaining consent prior to administering the immunization;
• Provide to each immunization recipient or legally responsible person, a signed certificate of immunization noting the recipient’s name, date of immunization, address of immunization, administering nurse, immunizing agent, manufacturer and lot number, and recommendations for future immunizations;
• If the immunization recipient or the legally responsible person consents and the recipient has a primary care practitioner/provider, the information provided to the recipient must be communicated to the recipient’s PCP;
• Have available on site, agents to treat anaphylaxis including, but not limited to, epinephrine and necessary needles and syringes;
• Report all adverse immunization outcomes to the Vaccine Adverse Reporting System (VAERS) using the appropriate form;
• Ensure a record of all persons immunized including: the non-patient specific standing order and protocol utilized, recipient’s name, date, address of immunization, immunizing agent, manufacturer and lot number of administered vaccine(s) and recommendations for future immunizations;**
• Ensure a record is kept of all potential recipients recording refusal(s) to be immunized.**

**Section 29.2 of the Rules of the Board of Regents requires that all patient records be retained for at least six years. Obstetrical records and records of minors must be retained for at least six years or until one year after the minor reaches the age of 21, whichever is longer.

Children Only: 

All RNs immunizing children in accordance with non-patient specific standing orders and protocols must be employed by or act as an agent of the Visiting Nurses Association or an equivalent organization as determined by the Department that is legally authorized to provide nursing services or for a state, county, municipal or other government agency. 

Requirements for Administration of Agents to Treat Anaphylaxis Using Non-Patient Specific Orders and Protocols:

Adults and Children: 

• All RNs must follow non-patient specific standing orders and protocols authorized by a physician or a certified nurse practitioner.
• All RNs must maintain or ensure the maintenance of a copy of the standing order(s) and protocol(s) that authorizes them to administer anaphylactic treatment agents. 
• The non-patient specific standing order for anaphylactic treatment agents must contain: 
  • Language authorizing RNs to administer agents used in the treatment of anaphylaxis;
  • The name(s) and license number(s) of RNs individually authorized to administer the prescribed anaphylactic treatment agents or
  • The name of the entity that is legally authorized to employ or contract with RNs to provide nursing services (eliminating the need to name all RNs individually), including administering prescribed agents to treat anaphylaxis;
  • A statement that RNs not named individually can not administer anaphylactic treatment agents outside of this employment or contract situation using this standing order or protocol. (This requirement does not preclude RNs from acting as Good Samaritans and providing care in an emergency situation.);
  • The specific agents used to treat anaphylaxis including, but not limited to, epinephrine that the RN(s) are authorized to administer;
  • The period of time that the order is effective, including beginning and ending dates.
  • A protocol prescribing actions to be taken by the authorized RNs when administering anaphylactic treatment agents in accordance with the non-patient specific standing order;
  • The name, license number and signature of the prescribing physician or certified nurse practitioner.
    
    
• The protocol for administration of anaphylactic treatment agents must require the RN to:
  • Ensure a record is kept of all persons who received epinephrine and/or other agents to treat anaphylaxis including, but not limited to: the non-patient specific standing order and protocol utilized, the recipients name, date, address of administration, administering nurse, and anaphylactic treatment agent, manufacturer and lot number administered (See previous reference to Section 29.2 of the Rules of the Board of Regents.);
  • Contact the local emergency medical services system following administration of anaphylactic treatment agent(s), or ensure that equivalent follow up is provide through other arrangements, and report to EMS or other follow up care providers which anaphylactic treatment agent(s) were administered when, the dose, strength and route of administration;
  • Report above noted information regarding administration of agents to treat anaphylaxis to the recipients primary care practitioner/provider, unless unable to obtain this information from the patient.

How to Get Involved

For Employees and Contract RNs: 

• Talk with your colleagues and employer(s) about the immunization needs of the population your facility or agency serves.
• Establish an interdepartmental workgroup to identify how your facility or agency will assess each patient entering your system for their immunization needs and develop policies and procedures on how to meet those needs.
• When will patients be assessed, and by whom
• When will they be immunized, and by whom
• Work with the medical and nurse practitioner staff to develop and approve non-patient specific standing orders and protocols that are in compliance with the regulations for use throughout your agency.
• Educate all staff regarding the immunization initiative and all involved staff regarding the standards of immunization practices, their roles and responsibilities regarding this initiative and your facilities/agencies program. All RNs must be CPR certified.
• Initiate and maintain a quality improvement plan to assess and improve upon your levels of success in immunizing your patients. 

For Individuals and Groups Wishing to Become Involved 

• Contact you local immunization coalition for assistance with planning and resources.
• Work with local physicians and nurse practitioners to develop agreed upon non-patient specific standing orders and protocols.
• Determine dates, times and locations for clinic(s) and market appropriately.
• Determine amount and types of vaccines, emergency drugs and equipment, syringes, other equipment, vaccine information statements, consent forms, certificates of immunization, copies of orders and protocols and staffing necessary to run the clinic.
• Ensure that all RNs participating are up to date on CPR, current standards for immunization practices, their roles and responsibilities relative to this initiative and administration of immunizations using non-patient specific standing orders and protocols.
• Maintain records on all recipients and potential recipients who refused immunization.
• If anaphylaxis occurs, follow standing order and protocol requirements.
• Report information regarding immunizations and/or anaphylactic treatment agents administered to recipients primary care practitioners/providers with permission when needed.
• NB: If you plan to immunize children during this clinic, you must enter into an agreement with an entity legally authorized to provide nursing services, including immunizations or a government agency, thus becoming an agent of the entity. 

New Rules for Unprofessional Conduct 

New rules for unprofessional conduct for the practice of nursing by registered nurses involved in the administration of immunizations and/or anaphylactic treatment agents following non-patient specific standing orders and protocols have been developed. In addition to prohibiting the general rules of unprofessional conduct for all professions and the health professions, the new rules state it is unprofessional conduct for RNs to:

• fail to adhere with any of the above noted regulatory requirements;
• administer an immunizing and/or anaphylactic treatment agent after the expiration date noted on the agent’s label;
• fail to store immunizing and/or anaphylactic treatment agents in accordance with directions found on the label, an official compendium or commonly known practices.

For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.

:: Nursing Practice | :: NYSNA Home